APPLICATION FOR LEAD CONTRACTOR LICENSE State Form 48739 (R7 / 4-11) Approved by State Board of Accounts, 2011 APPLICATION TYPE INDIANA STATE DEPARTMENT OF HEALTH APPLICATION TYPE: INSTRUCTIONS: 1. This form must be used to apply for a lead contractor license pursuant to 410 IAC 32. If accessing this form on-line, you may print the blank form and fill it out by hand; or you may fill it in on-line, then save it to your computer and print a hard copy for submission with original signatures. Please type or print in ink. Return this form, required addenda, and check or money order made payable to "ISDH Lead and Healthy Homes Program" by mail to: Cashier's Office Indiana State Department of Health PO Box 7236 Indianapolis, Indiana 46207 Type of application (check one): Initial license Renewal license 2. 3. PART A: GENERAL INFORMATION - TO BE COMPLETED BY ALL APPLICANTS 1. Applicant name Last First Middle Initial 2. 3. Company name: Company mailing address Street Company telephone number: Company FAX number: City State ( ( ) ) ZIP code PART B: PHOTOGRAPHIC IDENTIFICATION - APPLIES TO ALL APPLICANTS Pursuant to 410 IAC 32, the applicant shall provide the Department two (2) copies of a clear and recent one and one-half inch (1-1/2") by one and one-half inch (1-1/2") identifying digital photograph to be kept in your file. Please enclose your photographs with this application. LEAVE THESE SPACES BLANK FOR OFFICE USE ONLY PART C: DESIGNATED REPRESENTATIVE PERSONAL AND TRAINING INFORMATION - TO BE COMPLETED BY ALL APPLICANTS 4. Designated representative name Last First Middle Initial 5. Birthdate Day Year 6. / Sex Male Female 7. Height feet inches 8. Weight pounds 9. Month Eye Color 10. Hair Color 11. Home telephone number ( ) - / 12. E-mail Address 13. Supervisor License number: NOTE: Pursuant to 410 IAC 32, any transfer of the designated representative status to another employee must be reported to the Department, in writing, within five (5) working days of the transfer. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 48739 (R7 / 4-11) Application for Lead Contractor License 4/11 PART D: LICENSE RECIPROCITY ARE YOU APPLYING FOR AN INDIANA CONTRACTOR LICENSE BASED ON LICENSE RECIPROCITY?: YES - follow instructions below NO - skip to Part E and complete the rest of the application Companies applying for an Indiana license to conduct lead-based paint activities as a contractor under license reciprocity (see 410 IAC 32-2-7) must do the following: Complete Parts A, B, C, D and H of this application and submit the following with the application. 1. A legible copy of all of the applicant's or designated representative's current lead-based paint program licenses. 2. Documentation that the applicant or designated representative meets experience and education requirements of 410 IAC 32-2-3. 3. Copies of applicant's or designated representative's approved Project Supervisor initial and refresher training certificates and proof that applicant or designated representative has passed an approved third-party exam for Project Supervisor. 4. An up-to-date copy of the contractor's written standard operating procedures that includes current compliance procedures. 5. The contractor's certificate of insurance from a company recognized or licensed by the Indiana department of insurance. 6. Proof that the applicant or designated representative has attended an Indiana-approved lead-based paint two-hour Indiana Rules Awareness course. 7. Payment of the $150 application fee (see Part G of this application). PART E: CONTRACTOR MATERIALS TO BE SUBMITTED WITH APPLICATION Any contractor seeking an Indiana Lead Contractor License or Re-approval must provide the following: 1. 2. A complete list of prior contracts for the previous thirty-six (36) months for lead projects, including names, addresses, and telephone numbers of persons for whom projects were performed. An up-to-date copy of the contractor's written standard operating procedures, which include current compliance procedures for the following regulatory programs: a) b) c) d) e) 3. 4. 5. 410 IAC 32-4 (Abatement procedures for all projects), 410 IAC 32-5 (Work Practice Standards), 410 IAC 32-2 (Lead Management Personnel; Licensing), 326 IAC 10 (Solid Waste) 29 CFR 1926.62 (Occupational Safety and Health Standards, Subpart 1, Personal Protective Equipment). A description or any lead projects that the contractor conducted which were prematurely terminated or not completed, including the circumstances surrounding termination. A list of any contractual penalties related to lead-based paint activities that the contractor has paid for noncompliance with contract specifications. Copies of any and alI warning letters, Notice and Order of the Commissioner, Agreed Orders, citations, notices of violation, or findings of violation levied against the contractor by any federal, state, or local governmental agency for violations of regulations or other laws pertaining to lead activities, including names and locations of the projects, the dates, and a description of how the allegations were resolved. A description detailing all legal proceedings, lawsuits, warning letters to supervisors from ISDH or claims which have been filed or levied against the contractor or any of his past or present employees, while employed by said contractor, for lead-related activities. 6. PART F: FINANCIAL RESPONSIBILITY 410 IAC 32-2-4(b)(12) requires that a contractor provide documentation of the contractor's financial responsibility with a current certificate of insurance with at least five hundred thousand dollars ($500,000) of liability insurance. The company offering insurance coverage must be recognized or licensed by the Indiana Department of Insurance. The Indiana State Department of Health must be listed as a "certificate holder" on the insurance. Attach documentation of this financial responsibility. Any changes in the status of the contractor's financial responsibility must be reported, within five (5) working days, to the Indiana State Department of Health. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 48739 (R7 / 4-11) Application for Lead Contractor License 4/11 PART G: CONTRACTOR LICENSE APPLICATION FEE Upon application for an initial or renewal lead contractor license, the applicant shall pay a fee in the amou